When Cass Daniels began telling his partner, friends and family that he was thinking about transitioning back in 2015, his mother was supportive of his plans but had a strong ― and unexpected ― reaction to the news. She wanted to talk about parenthood.
“When I first came out as trans, I wasn’t sure if I even wanted to start testosterone or if I wanted to just do a natural transition,” he said, now 27 years old. “But she was very adamant and had a lot of questions about whether or not I was going to have a biological child.”
Assigned female at birth, Daniels, a social worker, had always known that he wanted to be a parent one day. So when he began actively preparing to begin his transition, he knew he wanted to take extra steps to preserve his fertility before beginning any kind of hormone replacement therapy.
He put off the testosterone treatment that would lower his voice, increase muscle mass and make facial hair thicker, looked up a fertility clinic, and began instead to take estrogen in preparation for an egg retrieval.
“It was an interesting thing to go from telling my family and friends, ‘Hey, I think I’m trans,’ to having to give myself shots of estrogen, which was the opposite of what I was looking for,” he said. “But I knew the end result would be that I would have a baby that was genetically mine.”
Last year, Daniels and his partner, Cammie Daniels, purchased donor sperm, fertilized Daniels’ frozen eggs and then placed an embryo into Cammie. The result: Reece, a healthy baby girl born last August.
Listen to Episode 3 of IVFML Becoming Family below.
There’s little information on the number of transgender people in the U.S. who take steps to preserve their fertility before or after transition. A Toronto survey of childless trans people found that, although 21 percent wanted to have a child in the future, only 3 percent had banked either eggs or sperm. Other studies on trans youth found that rates of fertility preservation were also low ― less than 5 percent. We also know that about 1.4 million American adults identify as transgender. And several studies suggest that one-quarter to one-half of these adults are also parents.
However, transgender people who transition later on in life are more likely to say they are parents compared to those who transition in early adulthood, indicating a majority of trans parents may have had their children before transitioning, according to a 2014 Williams Institute review of transgender parenting research.
As more people are coming out as transgender or gender nonconforming at earlier ages, interest in fertility preservation for this population is rising, experts say. For young people like Cass, who know they want to transition and that they want to have genetically related children in the future, it would be best to take steps to preserve their fertility before beginning hormone treatment for transition.
But there are significant barriers that prevent the trans community from following these guidelines, including poverty, discriminatory definitions about who needs infertility treatments and a lack of culturally competent health care providers around the country.
While infertility treatment is an expensive, out-of-pocket process for most people, the little insurance coverage that exists relies on a premise that fundamentally discriminates against LGBTQ identities. A trans person cannot meet the traditional medical definition of infertility used by insurance companies, for example, because it is defined as a man and woman having unprotected sex for six to 12 months.
Because of this, even if a trans person did have infertility treatment coverage, they wouldn’t be able to qualify as “infertile” to use it, making all treatments out-of-pocket. Egg freezing can cost as much as $15,000, though sperm banking tends to cost no more than $1,000.
Daniels was dismayed to find that he had no health insurance coverage whatsoever for the costs.
“I sat on the phone for hours trying to file a claim because, at that time, the [Affordable Care Act] had kind of said you had to cover trans-related procedures,” he said. “They were refusing to cover pretty much anything.”
Thankfully, Daniels’ mom, who had initially raised the question about grandchildren, gave him and his partner $12,000 to cover the cost of the egg freezing. She later gave the couple another $8,000 to cover the cost of donor sperm and embryo implantation.
“I am privileged, and I recognize that privilege,” Daniels said. “I know how hard it is for people to realize that they will not be able to have their own genetic child unless they can afford egg retrieval or decide to carry the baby themselves.”
These financial considerations put fertility preservation out of reach of most people who are initially transitioning, said Dr. Ward Carpenter, director of the transgender health program at the Los Angeles LGBT Center.
Complicating things further, there is a massive variability in the quality and accessibility of trans health care in general. The World Professional Association for Transgender Health guidelines say that hormone-prescribing physicians have the responsibility to discuss how hormone replacement therapy could cause a reduction in fertility and that fertility preservation options should be discussed before starting on any medications.
Trans health in general is a small field, and specialists tend to be concentrated in major cities and along the coasts. General practitioners may want to help but may know only the basics about how to start hormone replacement therapy.
There are instances where transgender people who have already begun hormone replacement therapy have gone off these hormones in order to conceive, but there’s no guarantee that they will be able to fully recover their fertility.
For instance, taking testosterone will eventually cause a person to stop ovulating and menstruating, while estrogen will lower sperm count and quality. It takes time to recover those bodily functions ― if you can recover them at all.
But beyond the biological uncertainties, going off hormones after being on them for so long presents an emotionally fraught step, said Dr. Maurice Garcia, director of the Cedars-Sinai transgender surgery and health program in Los Angeles. By the time they see a surgeon like Garcia to get gender-affirming surgery, they’ve likely been on hormone replacement therapy for years and can’t imagine going backward to do a fertility treatment.
“People are very loathe to want to get off hormones for a minimum of three to six months in order to let the effects of the hormones wash away so they can bank healthy sperm or eggs,” Garcia said. “So the best time to do [fertility preservation] is before they even start hormones.”
There’s also the uncertainty about what level of care a trans person will get from the fertility clinic itself. Are the doctors and staff understanding of trans identities and willing to use their preferred pronouns, especially when it comes to medical treatment about bodily functions that are so strongly intertwined in historical and traditional ideas about gender?
And if a person is transitioning on their own by buying hormones outside the medical care system, that lowers their chances even further that they will get this kind of education, Garcia said. There are no data on how many people are doing this, but an estimated 97 percent of all websites selling pharmaceutical drugs are unlawful.
Choosing between mental health and a future family
Daniels considered delaying fertility preservation in order to start on testosterone right away but ultimately decided that it would be detrimental to his well-being to begin transition, stop to do an egg retrieval and then resume.
“I knew mentally I was going to be on path toward becoming myself,” he said about his long-term goal to transition. “And then to abruptly stop that and kind of go back to injecting myself with female hormones ― that just didn’t seem like something that would support my mental health.”
When he finally chose a fertility clinic in Denver to do his egg retrieval, his doctors ― at the Colorado Center for Reproductive Medicine, a North American network of fertility clinics ― were supportive and helpful about Daniels’ fertility goals.
“They were talking about me having my period, and they were still using male pronouns, and they were talking about retrieving my eggs and using male pronouns,” Daniels said.
On the day of his egg retrieval surgery, he banked 21 eggs ― and was elated to begin his transitioning process. Still under the effect of the anesthesia, he told anyone who would listen that he was trans.
“The nurse that was there was so kind,” he said. “I felt safe enough to tell that person I was trans, and that doesn’t typically happen in medical settings.”
In a few years, Daniels and his partner hope to use sperm from the same donor to help Cammie conceive with her own eggs, making a genetically related half-sibling for Reece.
Daniels is aware of how lucky he is to have been able to freeze his eggs before transition. When his daughter was born, trans friends asked how this was possible ― and were disheartened to understand that they probably would never be able to afford the same treatments that gave Daniels his daughter.
He also has other trans friends who managed to go off their hormones and get pregnant. But ultimately these barriers to trans fertility are unfair and need to change, Daniels said, because they force people to choose between their own mental health and a future family.
“I know how hard it is for people to realize that they will not be able to have their own genetic child unless they can afford egg retrieval or decide to carry the baby themselves.”
CORRECTION: A previous version of this story indicated there was little information on the percentage of trans people who are preserving their fertility. In fact, there is a handful of studies that show the rates of egg and sperm banking are low in this population.